Knee joint capsular disruption and repair

ABSTRACT

Meniscal extrusion can occur due detachment of the knee capsule from structures of the knee. Disclosed herein are methods to repair the meniscal detachment. Additionally, cadaveric and synthetic models can be used to teach said methods of repair.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.15/596,015, filed May 16, 2017, which claims priority under 35 U.S.C. §119(e) to U.S. Provisional Patent Application Ser. No. 62/337,059, filedon May 16, 2016, and entitled “Meniscal Capsular Disruption and Repair,”and to U.S. Provisional Patent Application Ser. No. 62/470,473, filed onMar. 13, 2017, and entitled “Knee Joint Capsular Disruption And Repair.”The full disclosures of U.S. patent application Ser. No. 15/596,015,U.S. Provisional Patent Application Ser. No. 62/337,059, and U.S.Provisional Patent Application Ser. No. 62/470,473 are incorporatedherein by reference.

BACKGROUND

The disclosure herein describes methods of treating extrusion of themeniscus, which can possibly delay the early onset of osteoarthritis,further meniscal damage, and meniscal root pathology.

The meniscus is a crescent-shaped cartilage pad that functions tocushion and stabilize the knee joint. In particular, the meniscus actsas a shock absorber between the femur and the tibia. A common kneeinjury is meniscal extrusion, which occurs when the meniscus drifts fromits anatomical position in the knee. When the meniscus is in an extrudedposition, there is reduced function of the meniscus in cushioning andstabilizing the knee joint. Meniscal extrusion is often associated withmeniscal degeneration, a meniscal tear (e.g., a radial tear, alongitudinal tear, or an oblique tear), a torn meniscal root, and/orosteophyte formation.

Current methods of treating a meniscal extrusion include bothnon-surgical treatment and surgical repair. Non-surgical treatment isoften attempted prior to surgical repair, and example non-surgicaltreatment includes physical therapy and/or insertion of biologics tofacilitate the healing of the meniscus. However, in the event thatnon-surgical treatment is not successful in treating the meniscalextrusion, surgical repair can be performed to treat the meniscalextrusion. Surgical repair is usually performed arthroscopically, and aknee arthroscopy to treat the meniscus typically includes repairing anymeniscal tear(s) and/or repairing a torn meniscal root. Knee arthroscopycan also include removal of osteophytes that have formed.

Current surgical repair methods for treating a meniscal extrusion havevarious drawbacks. For example, current methods do not treat theunderlying injury that results in a meniscal extrusion. The meniscusdrifts due to a disruption in the capsule of the knee, whereby thecapsule becomes detached from at least one structure of the knee joint(e.g., the meniscus, tibial periosteum, femoral periosteum, etc.) and/orthe meniscotibial ligament (MCL) detaches from its insertion point.Capsular disruption can occur concomitantly with a meniscal root tear.Alternatively, capsular disruption can occur, followed by meniscalextrusion, which then leads to a meniscal root tear. Current methods fortreating a meniscal extrusion do not adequately address or treat thecapsular disruption. Since current surgical repair methods do not treatthis capsular disruption, the underlying injury that results in themeniscal extrusion remains after current surgical repair methods. Thus,surgical repair methods, and symptom relief, may only be temporary sincethe underlying injury remains. After time, the surgically repairedmeniscus can begin to extrude again.

Improved systems and methods for repairing a meniscal extrusion areneeded. In particular, systems and methods that treat the underlyinginjury that results in a meniscal extrusion are needed. Systems andmethods for teaching improved systems and methods for repairing ameniscal extrusion are also needed.

SUMMARY

A capsular disruption can result in meniscal extrusion, which occurswhen the meniscus drifts from its anatomical position in the knee. Themeniscus drifts medially or laterally (“extruding” from the knee joint).The meniscus drifts due to a disruption in the capsule of the knee,whereby the capsule becomes detached from at least one structure of theknee joint (e.g., the meniscus, tibial periosteum, femoral periosteum,etc.) and/or the meniscotibial ligament detaches from its insertionpoint. The capsule can develop laxity and/or tears through degenerationor trauma to the three layer structure of the medial and/or lateralcapsule. Additionally or alternatively, the capsule can develop laxityand/or tears through degeneration or trauma to the meniscotibial fibersof the meniscotibial ligament. Capsular disruption can occurconcomitantly with a meniscal root tear. Alternatively, capsulardisruption can occur, followed by meniscal extrusion, which then leadsto a meniscal root tear. A meniscal root tear is often associated withthe subsequent short or long term development of osteoarthritis.

As a particular example of capsular disruption resulting in meniscalextrusion, the medial inferior knee capsule can begin peeling away fromthe tibia, and this peeling away can lead to meniscal extrusion. Themedial inferior knee capsule can peel away from the tibia for variousreasons, such as trauma and/or degeneration. In an example, the traumaand/or degeneration causes coronary fibers of the meniscotibial ligamentto detach from the tibia. When the medial inferior knee capsule peelsaway from the tibia, the meniscus loses a portion of support, and theanterior horn of the medial meniscus can incur further trauma. Thisfurther trauma leads to a disruption of this attachment point of themeniscus, allowing the meniscus to extrude to a greater distance. Whenthe meniscus is in the extruded position, there is reduced function ofthe meniscus in cushioning and stabilizing the knee joint. Continuedmicro-motion of meniscus extrusion can further progress the disruptionof the capsule from the tibia. As the meniscus further extrudes, theposterior horn of the meniscus can become avulsed.

Although the above example describes a progressive extrusion from theanterior to the posterior aspect of the knee, other example progressionsare possible as well. For instance, it is also possible that a traumaticevent or degeneration can cause a disruption to the posterior horn ofthe medial meniscus, thereby leading to the progressive extrusion of themeniscus from the posterior to anterior aspect of the knee.Additionally, although the above example describes a capsular disruptionof the medial inferior knee capsule, in other examples the lateral kneecapsule peels away from the tibia. Furthermore, although the aboveexamples describe the knee capsule peeling away from the tibia, the kneecapsule can peel away from other structures of the knee joint. Forinstance, in other examples, the knee capsule peels away from the femur.

Disclosed herein are methods of repairing a capsular disruption tore-attach the capsule to a knee structure. A repair of capsulardisruption can be performed concomitantly with a meniscal root repair.If the meniscal root is not torn, the capsular disruption can berepaired so the meniscus does not extrude further, and the conditiondoes not progress to a torn meniscal root. An embodiment includesinserting one or more anchors through the capsule. The anchor can beinserted into a knee joint structure to re-attach the capsule to thatstructure.

The methods and systems in accordance with the present disclosurebeneficially provide improved methods and systems for repairing ameniscal extrusion. In particular, the disclosed methods and systemstreat the underlying injury of capsular disruption that leads to ameniscal extrusion. By treating this underlying injury, the disclosedmethods and systems of repairing a meniscal extrusion result in a moreeffective repair of the meniscal extrusion compared to existing repairsof meniscal extrusions. Furthermore, in accordance with exampleembodiments, the disclosed methods and systems also provide improvedmethods and systems for teaching and/or practicing repair of a meniscalextrusion.

In an example in accordance with the present disclosure, methods ofrepairing capsular disruption are described. The methods includeinserting one or more anchors through a knee joint capsule of a knee.The method further includes inserting the one or more anchors into aknee joint structure to secure the knee joint capsule to the knee jointstructure.

In another example in accordance with the present disclosure, methods ofcreating a capsular disruption are described. A method includes placingan instrument between a knee joint capsule of a knee and a knee jointstructure of the knee. A method then includes disrupting the attachmentof the knee joint capsule from the knee joint structure by physicallyelevating the instrument to force a capsular disruption. In anembodiment, the instrument has a flat surface (e.g., a banana blade) sosoft tissue is not cut when the instrument is elevated.

In another example in accordance with the present disclosure, methods toteach or practice repairing meniscal extrusion are described. A methodincludes using a cadaveric knee to teach or practice a method ofrepairing a capsular disruption, wherein said method comprises (i)inserting one or more anchors through the knee joint capsule and (ii)inserting the one or more anchors into the knee joint structure tosecure the knee joint capsule to the knee joint structure. In anotherembodiment, a cadaveric knee is used to teach repairing a meniscal tearin combination with repairing a capsular disruption.

In another example in accordance with the present disclosure, a methodto teach or practice repairing a meniscal extrusion is described. Themethod includes using a synthetic knee to teach or practice repairingthe meniscal extrusion, wherein the synthetic knee comprises a syntheticknee joint capsule and a synthetic knee joint structure. Using asynthetic knee to teach or practice repairing the meniscal extrusionincludes (i) inserting one or more anchors through a synthetic kneejoint capsule of a synthetic knee and (ii) inserting the one or moreanchors into a synthetic knee joint structure to repair a capsulardisruption by securing the synthetic knee joint capsule to the syntheticknee joint structure.

In another example in accordance with the present disclosure, a kneemodel is described. The knee model includes at least part of a tibia, atleast part of a femur, a detachable meniscus, a detachable knee capsule,and a detachable meniscotibial ligament, wherein all of the componentsare synthetic.

The features, functions, and advantages that have been discussed can beachieved independently in various embodiments or can be combined in yetother embodiments further details of which can be seen with reference tothe following description and drawings.

BRIEF DESCRIPTION OF THE FIGURES

FIG. 1 illustrates an example meniscal extrusion, according to anexample embodiment.

FIG. 2 illustrates an example meniscal extrusion, according to anexample embodiment.

FIG. 3 illustrates an example meniscal extrusion, according to anexample embodiment.

FIG. 4 illustrates an example meniscal extrusion, according to anexample embodiment.

FIGS. 5-14 illustrate various example steps of repairing at least one ofa capsular disruption or a meniscal extrusion, according to an exampleembodiment.

FIG. 15 illustrates an example ultrasound showing an intact capsule andan intact meniscus on a cadaveric knee, according to an exampleembodiment.

FIG. 16 illustrates an example ultrasound showing meniscal extrusion ofthe meniscus medially, according to an example embodiment.

FIG. 17 illustrates an example ultrasound showing an extrusion of themeniscus medially, according to an example embodiment.

FIG. 18 illustrates an example knee, according to an example embodiment.

FIG. 19 illustrates a close-up, cross-sectional view of a joint capsulealong the middle third of the medial side of the example knee of FIG.18, according to an example embodiment.

DETAILED DESCRIPTION

Disclosed embodiments will now be described more fully hereinafter withreference to the accompanying drawings, in which some, but not all ofthe disclosed embodiments are shown. Indeed, several differentembodiments may be described and should not be construed as limited tothe embodiments set forth herein.

A method of repairing a capsular disruption to re-attach the capsule toa structure is disclosed herein. Meniscal extrusion can occur when thereis capsular disruption, i.e., detachment or tearing of the knee capsulefrom at least one structure of the knee joint. In an embodiment, acapsular disruption tear can be less than 0.5 mm, about 0.5 mm, about 1mm, about 2 mm, about 3 mm, about 4 mm, about 5 mm, about 6 mm, about 7mm, about 8 mm, about 9 mm, about 10 mm, or about more than 10 mm.Medial or lateral drift of the meniscus (i.e., meniscal extrusion) canbe about 5%, about 10%, about 15%, about 20%, about 25%, about 30%,about 35%, about 40%, about 45%, about 50%, about 55%, about 60%, about65%, about 70%, about 75%, or about more than 75%. In an embodiment,injuries can be graded according to the length of the tear incombination with the percent extrusion. For example, a Grade 1 injuryoccurs when there is minimal capsular disruption with a 10% or lessmeniscal extrusion. A Grade 2 injury occurs when there is a 3 mm or lesstear with a 25% or less meniscal extrusion. A Grade 3 injury occurs whenthere is an 8 mm or less tear with a 50% or less meniscal extrusion. AGrade 4 injury occurs when there is an 8 mm or more tear with a 50% ormore meniscal extrusion. Other meniscal-injury grading scales can beused as well and may change over time with greater research afterrecognition of the underlying injury.

FIGS. 1-4 illustrate various example meniscal extrusions. In particular,FIG. 1 illustrates a knee 100 having an example Grade I injury 102. Inthis example, there is a 10% or less meniscal extrusion 104. In thisexample injury 102, there is also a sprain with edema in the tissue orassociated marrow attachment of the meniscotibial ligament 106.Furthermore, in this example injury 102, there is no medial collateralligament (MCL) sprain or involvement other than edema, and there are noor minimal osteophytes present.

FIG. 2 illustrates a knee 110 having an example Grade II injury 112. Inthis example, there is a 25% or less meniscal extrusion 114. There isalso a 3 mm or less capsule disruption tear 116 in which the capsule 118is separated from the tibia 120. Furthermore, in this example, there canbe mild degeneration, such a minimal meniscal degeneration or cleavagetear. For instance, FIG. 2 shows mild degeneration 122. In this exampleinjury 112, there is also a mild sprain of the MCL 124, and there are noor minimal osteophytes present. The meniscal extrusion 114 is reduciblewith compartment dynamic off-loading.

FIG. 3 illustrates a knee 130 having an example Grade III injury 132. Inthis example, there is a meniscal extrusion 134 of approximately 25-50%.There is also a 8 mm or less capsule disruption tear 136 in which thecapsule 138 is separated from the tibia 140. Furthermore, in thisexample there can be moderate meniscal degeneration and/or osteophyteformation. For instance, FIG. 3 shows moderate degeneration 142 andosteophyte 144. In this example, the meniscal extrusion 134 is reduciblewith compartment dynamic off-loading. However, due the osteophyteformation, the meniscus 146 may or may not be fully reducible.

FIG. 4 illustrates a knee 150 having an example Grade IV injury 152. Inthis example, there is a meniscal extrusion 154 of approximately 50% ormore. There is also a 8 mm or less capsule disruption tear 156 in whichthe capsule 158 is separated from the tibia 160. Furthermore, in thisexample there can be severe meniscal degeneration or tearing withosteophytes present. For instance, FIG. 4 shows severe degeneration 162and osteophytes 164 a-b. In this example, the meniscal extrusion 154 isnot substantially reducible with compartment dynamic off-loading.

Disclosed herein are methods of repairing a capsular disruption thatproduce meniscal extrusions as shown in FIGS. 1-4. An example method ofrepair includes inserting one or more anchors through the capsule. Theanchor can be inserted into a knee joint structure to re-attach thecapsule to that structure. Any suitable anchors are possible. Forinstance, in an example embodiment, the anchor is a suture anchor(knotless or knotted; e.g., a SutureTak® anchor, Quattro® Link knotlessanchors, Twinfix® anchors, Bioraptor® anchors, Spyromite® anchors,Dynomite® anchors, Osteoraptor® anchors, Raptomite® anchors, JuggerKnot®anchors, JuggerKnotless® anchors, etc.), a soft tissue anchor (e.g.,Eclipse™ soft tissue anchor, Piton™ soft tissue fixation implant, etc.),or the like. In another example, the anchor is a staple. Other anchorsare possible as well.

In an example embodiment, a method for repairing a capsular disruptionis performed to repair a capsular disruption before a meniscal extrusionhas occurred. In another example, the method for repairing a capsulardisruption is performed to repair a capsular disruption that resulted inan associated meniscal extrusion. For instance, the method for repairinga capsular disruption could be used to repair the capsular disruptionsresulting in meniscal extrusions shown in FIGS. 1-4.

An example method can involve positioning an arthroscope in a positionto allow visualization of the knee joint capsule and the knee jointstructure. The example method can involve placing a spinal needlethrough the skin into the knee joint space to mark an area above themeniscus. The example method can involve visualizing the spinal needlewith the arthroscope to identify a location for inserting one or moreanchors through the knee joint capsule. The example method can involve,for each anchor of the one or more anchors, drilling a socket in thebone for inserting the anchor into the bone. The method can involveinserting the one or more anchors through the knee joint capsule of aknee. The example method can involve inserting the one or more anchorsinto the drilled socket to secure the knee joint capsule to the kneejoint structure. The example method can involve securing flexiblestrands (e.g., suture, suture tape, etc.) from one anchor to anotheranchor.

This example method is described in further detail with reference toFIGS. 5-14. FIG. 5 illustrates a knee 240 upon which the example methodis performed. In this example, knee 240 is illustrated as a syntheticknee model. However, in other examples, the knee 240 is a knee of apatient. In yet other examples, the knee 240 is a cadaveric knee.

The knee 240 includes a knee joint capsule 252 and a knee jointstructure 254. As seen in FIG. 5, the example method involvespositioning an arthroscope 250 in a position to allow visualization ofthe knee joint capsule 252 and the knee joint structure 254. The examplemethod also involves placing a spinal needle 256 through the skin (notshown) into the knee joint space. Furthermore, the example methodinvolves visualizing the spinal needle 256 with the arthroscope 250 toidentify a location for inserting one or more anchors through the kneejoint capsule 252.

In the example of FIGS. 5-14, the area of the knee joint capsule 252through which the one or more anchors are inserted is the medialcapsule. However, in other example embodiments, an area of the kneejoint capsule 252 through which the one or more anchors are inserted isthe lateral capsule. Furthermore, in the example embodiment of FIGS.5-14, the knee joint structure 254 into which the one or more anchorsare inserted is the tibia. However, in other example embodiments, theknee joint structure 254 is the femur.

In the illustrated example, the one or more anchors include a firstanchor and a second anchor. FIGS. 5-7 illustrate identification of thelocation for inserting the first anchor and the insertion of the firstanchor. As seen in FIG. 5, the spinal needle 256 is placed in the kneejoint capsule 252 and is viewed with the arthroscope 250 to identify alocation for inserting the first anchor. The spinal needle 256 can enterthrough the knee joint capsule 252 above the meniscus and into the jointspace. The anchor placement can then be determined a certain distancedistal to this spinal needle 256 for capsular repair on the tibia. Themethod then involves making an incision in the knee joint structure 254for inserting the first anchor into the knee joint structure 254. Inparticular, drill pin 257 (see FIG. 6) can be used to drill a hole forinserting the first anchor into the knee joint structure 254. A drillguide 258 (see FIG. 7) can be used to guide the drill pin 257. The drillguide 258 with an anchor inserted through the cannulation of the drillguide 258 is used to place the anchor into the knee joint structure 254(see FIG. 7). The first anchor 260 (see FIG. 8) is placed in the drilledhole. The first anchor 260 is placed below the joint line 261 (see FIG.8) and through the capsule 252 at the anterior distal portion of thecapsule 252. In an example embodiment, the insertion of the first anchoris percutaneously inserting the anchor.

FIGS. 5 and 9 illustrate identification of the location for insertingthe second anchor and insertion of the second anchor. The spinal needle256 is placed in the knee joint 252 and is viewed with the arthroscope250 to identify a location for inserting the second anchor. The methodthen involves drilling a socket in the knee joint structure 254 forinserting the second anchor. In particular, as seen in FIG. 9, drillguide 258 is used to drill a hole through the capsule 252 and into theknee joint structure 254. The second anchor 262 (see FIG. 10) is thenplaced in the drilled hole. In this example embodiment, the secondanchor 262 is placed posterior to the first anchor 260.

In an example embodiment, the second anchor 262 is placed within about 2cm of the first anchor. In a more particular example, the second anchor262 is about 1 to about 2 or about 1 to about 1.5 cm from the firstanchor. However, other distances between the anchors are possible aswell (e.g., about 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, 1.0, 1.1, 1.2, 1.3,1.4, 1.5, 1.6, 1.7, 1.8, 1.9, 2.0, 2.1, 2.2, 2.3, 2.4, 2.5, 2.6, 2.7,2.8, 2.9, 3.0 cm, or more (or any range between about 0.3 and 3.0 cm)).

Although in this example the spinal needle 256 is inserted multipletimes and/or into multiple locations so as to determine the locationsfor inserting the two anchors, in other examples the spinal needle 256could be inserted a single time and/or at a single location. Thelocations for inserting the one or more anchors could then be identifiedrelative to position of the spinal needle 256. For instance, in anexample embodiment, the spinal needle 256 is placed between the femurand tibia at knee joint line 261, and the arthroscope 250 is used toconfirm that the spinal needle 256 is positioned at the joint line 261.The medical provider could select a distance from the knee joint line261 at which to insert the one or more anchors through the knee jointcapsule. The anchor is typically placed about 3 mm to about 5 mm belowthe knee joint line. The medical provider could then identify thelocation(s) for inserting the one or more anchors through the knee jointcapsule based on the position of the spinal needle at the joint line261. In particular, the spinal needle 256 at the joint line 261 can actas a guide for the medical provider so the medical provider is able toeasily visualize precisely where the joint line is located. This willhelp to ensure that the medical provider places the anchors 260, 262 adesired distance below the joint line.

Embodiments of the method of repair include bridging of the anchors byany type of flexible strand (e.g., suture, suture tape, etc.) Withreference to FIGS. 10-14, the method involves securing sutures from oneanchor to another anchor. First anchor 260 is a suture anchor thatincludes sutures 270, and second anchor 262 is a suture anchor thatincludes sutures 272 (see FIG. 10). A suture lead 274 from first anchor260 is fed into second anchor 262 (see FIG. 11). The suture lead 274 isthen tightened between the first anchor 260 and the second anchor 262(see FIG. 12). Suture lead 276 from the second anchor 262 is thenthreaded through to first anchor 260 and tightened (see FIG. 13).Securing the sutures from one anchor to another creates a bridge 280(see FIG. 14) between the first anchor 260 and the second anchor 262.This bridge 280 functions as a band that spans capsular tissue 252 andhelps to secure the capsule 252 to the knee joint structure 254. Thisbridge 280 also helps to prevent further meniscal extrusion.

Although the example embodiment illustrated in FIGS. 5-14 includesinserting two anchors 260, 262 to secure the knee joint capsule 252 tothe knee joint structure 254, more or fewer anchors are possible. Forinstance, in an example embodiment, three anchors are used to secure theknee joint capsule 252 to the knee joint structure 254. In an example,the first and second suture anchors about 1 cm to about 2 cm apart, andthe second and the third anchors are about 1 cm to about 2 cm apart. Asuture lead from a first anchor is fed into a second anchor; suture leadfrom the second anchor is fed into a third anchor; and a suture leadfrom the third anchor is fed into the first anchor. In another example,one anchor is used to secure the knee joint capsule 252 to the kneejoint structure 254. In yet another example, four or more anchors areused to secure the knee joint capsule 252 to the knee joint structure254.

In general, the number of anchors inserted to secure the knee jointcapsule 252 to the knee joint structure 254 can depend on the size ofthe capsular disruption. For instance, a suitable number of anchors isselected so as to cover the expanse of the tear and so that the anchorsare within about 2 cm or less of one another. Typically, more anchorsare selected for a larger tear than for a smaller tear. As a particularexample, a common capsular disruption tear is approximately 2.5 cm. Inan example, three anchors can be used for such a tear to secure the kneejoint capsule 252 to the knee joint structure 254. For instance, a firstanchor could be placed at or near the beginning of the tear (e.g., atthe 0 cm mark), a second anchor could be placed at or near the middle ofthe tear (e.g., 1.25 cm mark), and a third anchor could be placed at ornear the end of the tear (e.g., at the 2.5 cm mark). On the other hand,for a smaller tear, such as a 1-1.5 cm tear, one or two anchors can beinserted to secure the knee joint capsule 252 to the knee jointstructure 254. Other examples are possible as well.

Furthermore, although the illustrated example involved inserting sutureanchors and bridging those suture anchors together, other exampleanchors are possible as well. In general, any suitable tissue anchorscould be used. Other example methods include other knotless anchorsbridged with FiberTape® or SutureTape™, or a combination of knotted andknotless anchors and sutures. Furthermore, in some example embodiments,the tissue anchors are independent and are not bridged together.

In addition to inserting one or more anchors to secure the knee jointcapsule 252 to the knee joint structure, additional steps can be takento further treat the meniscal injury. For instance, in an exampleembodiment, the repair of capsular disruption can be performedconcomitantly with a meniscal root repair. If the meniscal root is nottorn, the capsular disruption can be repaired so the meniscus does notextrude further, and the condition does not progress to a torn meniscalroot and/or the development of osteophytes. Additionally oralternatively, the repair of capsular disruption can be performedconcomitantly with repair of other meniscal tears, such as a radialtear, a longitudinal tear, or an oblique tear. Furthermore, the repairof capsular disruption can be performed concomitantly with removal ofosteophytes formed in the knee joint.

Additional steps can also be taken to enhance the healing environmentfor a meniscal injury. In an example embodiment, the method includesroughening a knee joint structure 254 to induce bleeding, so as toprovide an enhanced healing environment. In an embodiment, the methodincludes using a rasp or like instrument to roughen medial tibialmetaphysis at the level of the lesion.

In an example embodiment, the method includes augmenting the repair ofthe at least one of the capsular disruption or the meniscal extrusion byinserting a biological product into the knee, so as to stimulate healingof the capsular disruption and the meniscal extrusion. Any suitablebiological product can be inserted to stimulate healing. For instance,in an example embodiment, the biological product is stem cells (e.g.,stromal stem cells), platelet-rich plasma (PRP), a tissue graft (e.g.,adipose, amnion, chorion, etc.), or combinations thereof. Other examplebiological products include bone marrow concentrate (BMC), bone marrowaspirate (BMA), growth factors, angiogenin, transforming growthfactor-β2 (TGF-β2), tissue inhibitors of metalloproteinases (e.g.,TIMP-1 and TIMP-2)), and growth factors, such as epidermal growth factor(EGF), platelet-derived growth factor (PDGF), vascular endothelialgrowth factor (VEGF), fibroblast growth factor (FGF), TGF-β(transforming growth factor-β), and combinations thereof. The biologicalproduct can be obtained from the patient to be treated or from anothersource. In an example, inserting the biological product into the kneetakes place prior to (i) inserting the one or more anchors through theknee joint capsule of a knee and (ii) inserting the one or more anchorsinto a knee joint structure to secure the knee joint capsule to the kneejoint structure. In another example, inserting the biological productinto the knee takes place after (i) inserting the one or more anchorsthrough the knee joint capsule of a knee and (ii) inserting the one ormore anchors into a knee joint structure to secure the knee jointcapsule to the knee joint structure.

In an embodiment, the meniscus and/or the methods described herein canbe visualized using an arthroscope. The arthroscope is a diagnostic andtherapeutic device utilized with minimally invasive orthopedic surgicalprocedures. The arthroscope provides direct visualization within theorthopedic articulating joint to assess or diagnose such anatomicalstructures as the meniscus, ligaments, tendons and articular surfaces.

The arthroscopist can follow a standardized approach for a completediagnostic knee arthroscopy. In an example embodiment, a diagnosticarthroscope includes visualization of areas around the patella includingthe suprapatellar pouch, medial and lateral gutter, intracondylar notch,posterior medial and lateral compartments as well as the medial andlateral compartment. Each compartment has specific anatomy toinvestigate. This investigation can utilize an arthroscopic probe fromthe opposite anterior portal. The probe allows the arthroscopist tomanipulate various anatomical structures to determine abnormalities tothese structures.

An anterolateral portal can initially be established prior toestablishing an anteromedial portal. The arthroscope and arthroscopicprobe can be interchanged between either portal for maximum efficiencyof the arthroscope or arthroscopic probe. Posteromedial andposterolateral portals can be established to fully appreciate thestructures in the posterior aspect of the knee joint.

The meniscus can be viewed intra-articular with the arthroscope.Meniscus hyper-mobility can be assessed with the aid of an arthroscopicprobe. The location of capsular disruption leading to meniscal extrusioncan be appreciated through the arthroscope as well as other diagnostictools. Utilizing the arthroscope for an intra-articular perspective ofthe meniscus, the medical provider can locate the beginning and endingpoint of extrusion that would correlate with capsular defect. In anexample embodiment, the medical provider inserts a needle from theoutside of the knee into the joint, verifying arthroscopically that theneedle is at the starting point of meniscal extrusion/capsulardisruption. The needle is used to mark the beginning and end points ofthe extrusion in the coronal plane (anterior to posterior aspect), andalso to assess anchor placement in the transverse plane (superior andinferior aspect).

The arthroscope can also be used to verify the presence of a meniscaland/or capsular lesion. With direct arthroscopic visualization, acapsular lesion can be produced and assessed and/or evaluated forresearch purposes.

In addition to or alternative to visualizing the meniscus and/or methodsdescribed herein with an arthroscope, the meniscus and/or the methodsdescribed herein can be visualized using other means. For instance, inother examples, the meniscus and/or the methods described herein can bevisualized using ultrasound, magnetic resonance imaging (MRI), and/oropen dissection with visual inspection of the medial or lateral capsulestructure with its associated bony attachment. Meniscal extrusion can beidentified by palpation, visualization (e.g., ultrasound), etc. In anexample, a capsular disruption and meniscal extrusion can be identifiedvia ultrasound, MRI, etc. prior to any procedure or teaching procedure(e.g., on a cadaveric knee).

FIGS. 15-17 illustrate example ultrasounds. FIG. 15 illustrates anultrasound 400 showing an intact capsule 402 and an intact meniscus 404on a cadaveric knee. FIG. 16 illustrates an ultrasound 410 showingmeniscal extrusion of the meniscus 412 medially. The capsule is detachedfrom the meniscus and/or tibial periosteum. FIG. 17 illustrates anotherexample ultrasound 420 showing further extrusion of the meniscus 412medially. A detailed diagnosis of the meniscal extrusion can beperformed using ultrasound in both a static and dynamic manner. In anexample, the diagnosis involves applying a valgus moment and/or a varusmoment to the knee and determining whether the meniscal extrusion isreducible based on the movement of the meniscus during the valgus and/orvarus movement. Additionally or alternatively, a detailed diagnosis canbe performed using ultrasound elastography (see, e.g., Drakonaki et al.,Br. J. Radiol. 2012, 85: 1435-1445).

Also disclosed herein are methods of producing a meniscal extrusioninjury in a cadaveric knee. A meniscal extrusion injury in a cadavericknee provides a model to teach diagnosis and/or repair of meniscalextrusion. An example method for disrupting a knee joint capsule of aknee (e.g., a cadaveric knee) from a knee joint structure includesplacing an instrument (e.g., a single sided banana blade scalpel)between a knee joint capsule of a knee and a knee joint structure of theknee. The example method then involves disrupting the knee joint capsulefrom the knee joint structure by physically elevating the instrument toforce a capsular disruption.

This example method is described in further detail with respect to FIGS.18-19. FIG. 18 illustrates an example knee 520 where the knee jointcapsule 522 is substantially intact with the tibia 524. In an example,knee 520 is a cadaveric knee. An instrument such as a probe or a scalpel(e.g., a banana blade scalpel) is placed between the knee joint capsule522 and tibia 524. For instance, the instrument can be placed at point526 between the knee joint capsule 522 and tibia 524. After being placedbetween the knee joint capsule 522 and tibia 524, the instrument isphysically elevated to force a capsular disruption. For instance, theinstrument can be physically elevated along the y-axis 530. Although inthis example the instrument is physically elevated along the y-axis, theinstrument can be physically elevated in other directions as well. Ingeneral, the instrument can be elevated in any direction suitable todisrupt the capsule from the knee joint structure (e.g., the tibia orthe femur). The extent of the forced capsular disruption can becontrolled based on the force applied to physically elevate theinstrument. Further, the extent of the capsular disruption can bemeasured by visualizing the knee with ultrasound, MRI, or othervisualization mechanisms.

In an embodiment, disrupting the knee joint capsule 522 from the tibia524 by physically elevating the instrument to force a capsulardisruption comprises tearing coronary fibers of a meniscotibialligament. FIG. 19 illustrates example coronary figures of ameniscotibial ligament. This close-up view of the medial capsule 522illustrates the three layer structure of the medial capsule, including(i) crural fascia 540, (ii) superficial portion 542 of the MCL 544, and(iii) the deep portion 546 of the MCL 544 including meniscofemoral andmeniscotibial extensions of the deep MCL. In particular, FIG. 19illustrates coronary fibers of the meniscotibial ligament 548 andcoronary fibers of the meniscofemoral ligament 550. Disrupting the kneejoint capsule 522 from the tibia 524 can include tearing the coronaryfibers of the meniscotibial ligament 548 from the tibia 524.

In an embodiment, meniscal extrusion occurs without any disruption orinjury to the meniscus. In another embodiment, detachment of themeniscotibial ligament produces a meniscal extrusion injury in additionto or independent to the capsule disruption.

Although in the example of FIG. 18 the knee joint capsule 522 isdisrupted from the tibia at a medial tibia below the joint line, theknee joint capsule 522 can be disrupted from the knee joint structure atother locations. For instance, in an example embodiment, the knee jointcapsule 522 is disrupted from the knee joint structure at a lateraltibia below a knee joint line. In another example, the knee jointcapsule 522 is disrupted from the knee joint structure at the femur 528.For instance, with reference to FIG. 19, disrupting the knee jointcapsule from the knee joint structure can include tearing the coronaryfibers of the meniscofemoral ligament 550 from the femur 528. Otherexamples are possible as well.

In an example embodiment, the knee 520 is used to teach a method ofrepairing at least one of a capsular disruption and a meniscalextrusion. In accordance with an example embodiment, an example methodfor teaching or practicing a method of repairing at least one of acapsular disruption and a meniscal extrusion involves providing acadaveric knee (e.g., cadaveric knee 520) comprising at least one of acapsular disruption or a meniscal extrusion. The example method theninvolves using the cadaveric knee to teach a method of repairing atleast one of a capsular disruption, wherein said using comprises (i)inserting one or more anchors through the knee joint capsule and (ii)inserting the one or more anchors into the knee joint structure tosecure the knee joint capsule to the knee joint structure.

In an example, providing the cadaveric knee includes providing acadaveric knee having a pre-existing capsular disruption or meniscalextrusion. Since meniscal extrusion is a common meniscal injury, manycadaveric knees can already have a pre-existing capsular disruption andmeniscal extrusion. In another example, if the cadaveric knee does nothave a pre-existing capsular disruption or meniscal extrusion, providingthe cadaveric knee can include (i) providing a cadaveric knee having asubstantially attached knee joint capsule and (ii) forcing a capsulardisruption in the cadaveric knee.

In addition to being used to teach repair of a capsular disruption andmeniscal extrusion, the knee 520 can also be used to teach diagnosis ofa capsular disruption and meniscal extrusion. For instance, the knee 520can be visualized with an ultrasound machine to facilitate teaching ofthe diagnosis. A valgus moment and/or a varus moment can be applied tothe knee, and the knee can be visualized with the ultrasound during thisapplied moment. The capsular disruption and meniscal injury can bevisualized more easily when being dynamically viewed compared to whenbeing viewed in a static image. Therefore, dynamically visualizing theknee 520 with the ultrasound machine can help to teach diagnosing thecapsular disruption and meniscal extrusion.

Disclosed herein is also a synthetic model of knee. The synthetic modelof the knee can be a model to simulate capsular disruption and for amedical provider to practice repair of meniscal extrusion. In thesynthetic model, a structure representing a capsule is detached from atleast one of the structures representing the meniscus, the femur, andthe tibia. In the synthetic model, there may or may not be a meniscalroot tear as well. A synthetic model as disclosed herein is configuredand adapted so that a medical provider can repair the meniscalextrusion, capsular disruption (e.g., meniscotibial ligamentdetachment), and/or meniscal root tear by any of the methods disclosedherein. In an embodiment, the same anchors and instrumentation that canbe used to make a repair in a patient can be used to make the repair ofthe simulated injury in the synthetic model. The synthetic model can bea Sawbones®-like orthopedic model, whereby the model can be used,demonstrated, practiced, etc. at a table top. The synthetic model canalso be a Sawbones®-like surgical model, whereby the model can simulatean arthroscopic surgery without the need for fluid. However, the modelcan accommodate portals and an arthroscope to better simulate surgery.In an embodiment, imaging equipment (e.g., ultrasound) can visualize aninjury to the knee capsule on a synthetic model as disclosed herein.

In an embodiment, a synthetic knee model include at least part of atibia; at least part of a femur; a detachable meniscus, wherein themeniscus can move to simulate extrusion and is also capable to tearingto simulate a meniscal lesion (e.g., a root tear); and a detachable kneecapsule, including a detachable meniscotibial ligament. In anembodiment, all of these components of the knee model are synthetic. Thedetachable meniscus, detachable knee capsule, and detachablemeniscotibial ligament can be capable of mimicking capsular disruptionand meniscal extrusion, such as the capsular disruption and meniscalextrusion shown in FIGS. 1-4.

In an embodiment, a knee model includes synthetic coronary fibersattached to the meniscus and/or the bone, wherein the meniscus is intactwhen connected to the coronary fibers and when the fibers disconnect,the meniscus can extrude. In an embodiment, the coronary fibers aredetachable and can be reattached. In an embodiment, a synthetic kneemodel includes a medial knee capsule where the superficial, middle, anddeep layer of the thickening at the convergence of the capsule andmedical collateral ligament where these layers can be visualized, evento the naked eye. In an embodiment, a synthetic knee model includes amedial knee capsule wherein a meniscotibial ligament can be visualizedand repaired.

In accordance with an example embodiment, an example method to teach orpractice repairing a meniscal extrusion using a synthetic model includesusing a synthetic knee to teach or practice repairing the meniscalextrusion, wherein the synthetic knee comprises a synthetic knee jointcapsule and a synthetic knee joint structure. The example methodinvolves inserting one or more anchors through a synthetic knee jointcapsule of a synthetic knee. The example method also involves insertingthe one or more anchors into a synthetic knee joint structure to repaira capsular disruption by securing the synthetic knee joint capsule tothe synthetic knee joint structure.

Knee 240 illustrated in FIGS. 5-14 is an example synthetic knee. In anexample embodiment, the synthetic knee 240 includes a syntheticmeniscotibial ligament with synthetic fibers, wherein the syntheticfibers are attached to a synthetic meniscus, and wherein the syntheticfibers are at least one of detached or detachable from the knee jointstructure. Including such detached or detachable synthetic fibers of themeniscotibial ligament can help a medical provider to teach and/orpractice diagnosis and repair of a capsular disruption and associatedmeniscal extrusion.

In an example, the synthetic knee is an ultrasoundable knee model thatcan be used to teach using an ultrasound during diagnosis and/or repairof the capsular disruption and meniscal extrusion. In such an exampleembodiment, the synthetic knee includes synthetic skin covering thesynthetic knee joint capsule and the synthetic knee joint structure. Anultrasound machine can be used to visualize the synthetic knee jointcapsule and the synthetic knee joint structure through the syntheticskin. This can help to teach diagnosis of a capsular disruption and ameniscal extrusion under more realistic conditions. This can also helpto teach use of an ultrasound to confirm the successful repair of thecapsular disruption and meniscal extrusion.

In an embodiment, the synthetic model is reusable, wherein a meniscalextrusion injury and repair can be performed more than once. A meniscalextrusion injury can be a capsule disruption (e.g., meniscotibialligament detachment), and/or meniscal root tear. In an exampleembodiment, a reusable synthetic model includes a removable insert thatincludes the capsule and/or the meniscus. By including a removableinsert, after performing a repair of a meniscal extrusion injury, therepaired insert can be removed and replaced with a new insert upon whichanother diagnosis and/or repair can be performed.

The disclosed methods described herein beneficially provide improvedmethods for repairing a meniscal extrusion. By repairing the underlyinginjury that results in the meniscal extrusion, the disclosed methods andsystems of repairing a meniscal extrusion result in a more effectiverepair of the meniscal extrusion compared to existing repairs ofmeniscal extrusions. In the event that the repair of capsular disruptionis performed concomitantly with a meniscal root repair, the resultingmeniscal root repair will beneficially be more effective than meniscalroot repairs using prior existing methods. In particular, by securingthe capsule to the knee structure, the meniscal root is less likely toexperience further trauma or degeneration. Similarly, in the event thatthe repair of capsular disruption is performed concomitantly with repairof another meniscal tear (e.g., a radial tear, a longitudinal tear, andoblique tear), the resulting meniscal tear repair is more effective thanmeniscal tear repairs using prior existing methods. This more effectiverepair of the meniscal extrusion can help to delay the early onset ofosteoarthritis, further meniscal damage, and meniscal root pathology.The disclosed methods of repairing a capsular disruption and meniscalextrusion also help to reapproximate the meniscotibial (coronary)ligament fibers while thus improving mechanotransduction through theassociated compartment of the knee joint.

The disclosed methods and systems also provide improved methods andsystems for teaching or practicing repair of a meniscal extrusion.

In accordance with certain embodiments of the present disclosure, any ofthe above-described methods may be performed on a living knee (e.g. theknee of a living human or animal) or a non-living knee. The non-livingknee may be a cadaveric knee or a synthetic knee, for example. Thenon-living knee may have or be caused to have a capsular disruption. Thenon-living knee may have a meniscal extrusion. The non-living knee mayhave a knee joint capsule and a knee joint structure, where the kneejoint structure may comprise at least one of meniscus, a tibia, a femur,tibial periosteum, or femoral periosteum.

Definitions

The term “capsule disruption” or “capsular disruption” refers to acondition where the capsule is detached from the meniscus and/or boneperiosteum (i.e., femoral and/or tibial). When the capsule loses thisattachment to other tissue(s), the meniscus can drift from itsanatomical position.

The term “meniscal extrusion” refers to the meniscus drifting from itsanatomical position, where the meniscus extrudes medially or laterally.

The term “joint capsule” refers to an envelope surrounding a synovialjoint, where the joint capsule includes an outer fibrous layer ormembrane and an inner synovial layer or membrane. On the inside of thejoint capsule, articular cartilage covers the end surfaces of the bonesthat articulate within that joint. The joint capsule surrounds the bonesjoined by the synovial joint to provide strength and lubrication.

The term “knee joint capsule” refers to an envelope that surrounds theknee joint and includes an outer fibrous layer or membrane and an innersynovial layer or membrane. The knee joint capsule surrounds the bonesof the knee to provide strength and lubrication.

The term “knee joint structure” refers to the portions of the kneeenveloped by and surrounding the knee joint capsule. In an exampleembodiment, the knee joint structure includes meniscus, the tibia, thefemur, tibial periosteum, and femoral periosteum.

The term “knee joint line” refers to the line through the most distalpoints of the medial and lateral femoral condyles in the coronal plane,or the line through the most distal point of the femur perpendicular tothe anatomical axis of the tibial shaft in the sagittal plane.

The term “meniscotibial ligament detachment” refers to the detachment ofthe meniscotibial ligament from the tibia and/or the meniscus. Themeniscotibial ligament is also known as the coronary ligament(s) of theknee. The meniscotibial ligament is continuous and contiguous with thejoint capsule and the menisci. More particularly, the meniscotibialligament is a portion of the joint capsule which connects the inferioredges of the fibrocartilaginous menisci to the periphery of the tibialplateaus. The capsule is not removed when the ligament is stripped fromits attachment at the medial tibial metaphysis. The meniscotibialligament is a distinct structure but is not an isolated structure likethe anterior collateral ligament. Rather, the meniscotibial ligament isa distinct thickening of the medial capsule, i.e., the convergence ofthe knee capsule and the medial collateral ligament, which attaches tothe meniscus and to the tibia. The coronary fibers of the meniscotibialligament hold the meniscus in place. The medial capsule has threelayers—superficial, medial, and deep. The meniscotibial ligament formsthe middle and deep layers.

The term “anterior” refers to what is in front of a subject and the term“posterior” refers to what is to the back of the subject. Furthermore,the terms “proximal” and “distal” are used to describe parts of afeature that are close to or distant from the main mass of the body ofthe subject, respectively.

EXAMPLES

Three example studies conducted in accordance with example embodimentsof the present disclosure are described below. In particular, the firstexample details a study regarding medial meniscus capsular disruption,according to an example embodiment. The second example details a studyregarding medial meniscus capsular repair, according to an exampleembodiment. The third example details a study regarding biomechanicaltesting to examine the effect of a medial meniscus capsular repair,according to an example embodiment.

Example 1: Medial Meniscus Capsular Disruption

A cadaveric lab was conducted to determine the possibility of creating alesion or disruption of the anterior inferior medial capsule of theknee, often associated with meniscus extrusion pathology.

Methods

A diagnostic ultrasound of a cadaveric knee was performed, mimicking theclinical steps: first starting with the specimen in a state ofrelaxation, then a valgus and varus load, followed by internal andexternal rotation. The medial and lateral menisci were intact asconfirmed by ultrasound (FIG. 17).

The anterior-middle third of the medial meniscus was located and anarthroscope was placed in a position under the meniscus to identify theintact capsular fibers of the capsule while using a probe to slightlyraise the meniscus. Using a single sided banana blade scalpel angled toroughly 80 degrees, the capsule was approached from a far lateralaccessory portal. Location of the banana blade was verified viaultrasound in conjunction with the arthroscope. By elevating the bladefrom the medial tibia below the joint line, the capsule was detachedfrom the tibial periosteum thereby producing capsular disruption. Uponcompletion of the arthroscopic portion, a diagnostic ultrasound wasperformed as previously described.

Results

The above procedure resulted in meniscal extrusion (FIG. 18). Carefuldissection of the area was completed to visualize the capsule andmeniscus. The capsule was efficiently elevated from the tibia with nodamage to the meniscus or capsular tissue.

Example 2: Medial Meniscus Capsular Repair

A repair of the capsule of cadaveric meniscal extrusion produced inExample 1 was completed using two knotless SutureTak® anchors. The firstanchor was placed anteriorly, and the second anchor placed posterior tothe first anchor. In an effort to reproduce a repair that could becompleted percutaneously, the sutures associated with each anchor werecarefully passed through the capsular tissue. Once this step wascompleted, the suture from the first anchor was loaded into the secondanchor to create a suture bridge. This was repeated with the suture fromthe second anchor back to the first and the incision was closed.

Verification of anchor placement was possible using the arthroscope anda spinal needle. The arthroscope was positioned to allow visualizationof the medial meniscus and capsule. The spinal needle was insertedthrough the skin on the medial side and visualized with the scope todetermine if the placement was inferior to the joint line and throughthe capsular tissue.

A diagnostic ultrasound was performed as described previously (FIG. 19).

The ultrasound confirmed that the meniscus remained intact through thevarious ranges of motion and applied stresses.

Example 3: Biomechanical Testing

Cadaveric knees were tested to determine the amount of naturalextrusion, to produce extrusion from an experimental lesion, and to testthe effect of repairing the experimental lesion.

Sample Preparation.

Six cadaveric knees were tested (3 male, 3 female, average age=60±7years) and were prepared by potting the femoral shaft in fiberglassresin. Three samples with evidence of meniscal extrusion or jointcapsule damage as examined by ultrasound were excluded from the testing.Suture tape was secured through the quadriceps tendon and reinforcedwith multiple medial-lateral rip stop passes of #2 sutures. A hole wasdrilled through the tibia and fibula, located 6.5 inches from the jointline, and a zip-tie was passed through both bones allowing for a 2.2 kgweight to be hung.

Mechanical Testing.

Mechanical loading of the knee samples was performed using two E10000Instron Electropulse Materials Testing Machines (INSTRON Corp., Canton,Mass.), with a 10 kN capacity load cells attached to the cross-head. Thespecimens were mounted in custom fixtures to the Instron testingsurface, such that the femur was held parallel to the ground, and theknee hung at 90° flexion. Suture tape secured to the quadriceps tendonwas strung though pulleys and tied off on a hook fixture suspended fromthe cross-head. The pulleys allowed for alignment of force vectors withthe direction of cross-head movement, and also ensured that the amountof travel to extend the knee would not exceed the travel limits of theInstron machine. A load was manually applied to the suture tape whichcaused the knee to move into full extension. The total cross-headdisplacement was recorded during this single cycle load for each kneesample tested. Each sample was subjected to sinusoidal cyclic loading inposition control using the displacement found in the single cycle loadfor amplitude at 0.2 Hz, for 100 cycles.

Sample Conditions.

Each sample was loaded through 100 flexion-extension cycles and wasexamined via ultrasound to determine the baseline position of the medialmeniscus relative to the medial aspect of the tibia. After examination,the joint capsule was detached from its attachment to the tibia, and themeniscotibial ligament was released from its insertion point. Then theknee was subjected to a second set of 100 loading cycles. The movementof the medial meniscus was determined via ultrasound, and the jointcapsule was repaired using 3.0 mm knotless SutureTak® anchors (Arthrex,Inc., Naples, Fla.). After a third set of 100 cycles, the position ofthe medial meniscus was determined a final time for comparison to thebaseline and damaged states. Ultrasound images were collected with theknee in extension, and under two conditions. First, the unloaded kneewas imaged, and then a 10 Nm valgus moment was applied to the jointusing a mounted force gauge and turnbuckle.

The following tables (i.e., Tables 1-6) show baseline, lesion, andrepair data for the six samples for (i) Meniscus Beyond Femoral-TibialBaseline (cm) (Pre-Cycle Resting, Pre-Cycle Varus Load, Post CycleResting, and Post Cycle Varus Load), (ii) Total Meniscus Length (cm)(Pre-Cycle Resting, Pre-Cycle Varus Load, Post Cycle Resting, and PostCycle Varus Load), and (iii) Capsular Displacement from Tibial Edge (cm)(Pre-Cycle Resting, Pre-Cycle Varus Load, Post Cycle Resting, and PostCycle Varus Load).

TABLE 1 Donor 1 Baseline Lesion Repair Meniscus Beyond Femoral-TibialBaseline (cm) Pre-Cycle Resting 0.18 0.30 0.24 Pre-Cycle Varus 0.20 0.360.26 Load Post Cycle Resting 0.19 0.25 0.22 Post Cycle Varus 0.20 0.330.22 Load Average 0.19 0.31 0.24 Total Meniscus Length (cm) Pre-CycleResting 0.62 0.86 0.86 Pre-Cycle Varus 0.75 0.87 0.93 Load Post CycleResting 0.78 0.95 0.85 Post Cycle Varus 0.69 0.88 0.87 Load Average 0.710.89 0.88 Capsular Displacement from Tibial Edge (cm) Pre-Cycle RestingNot Determined (ND) ND 0.23 Pre-Cycle Varus 0.11 0.23 0.18 Load PostCycle Resting ND ND 0.13 Post Cycle Varus 0.09 0.21 0.17 Load Average0.05 0.11 0.18

TABLE 2 Donor 2 Baseline Lesion Repair Meniscus Beyond Femoral-TibialBaseline (cm) Pre-Cycle Resting 0.16 0.39 0.28 Pre-Cycle Varus 0.20 0.410.27 Load Post Cycle Resting 0.23 0.39 0.27 Post Cycle Varus 0.26 0.470.27 Load Average 0.21 0.42 0.27 Total Meniscus Length (cm) Pre-CycleResting 0.81 0.88 0.81 Pre-Cycle Varus 0.89 0.87 0.88 Load Post CycleResting 0.89 0.86 0.93 Post Cycle Varus 0.86 0.88 0.86 Load Average 0.860.87 0.87 Capsular Displacement from Tibial Edge (cm) Pre-Cycle Resting0.06 0.13 0.16 Pre-Cycle Varus 0.09 0.19 0.14 Load Post Cycle Resting ND0.18 0.13 Post Cycle Varus 0.08 0.25 0.07 Load Average 0.06 0.19 0.13

TABLE 3 Donor 3 Baseline Lesion Repair Meniscus Beyond Femoral-TibialBaseline (cm) Pre-Cycle Resting 0.03 0.21 0.15 Pre-Cycle Varus 0.16 0.260.13 Load Post Cycle Resting 0.04 0.24 0.20 Post Cycle Varus 0.07 0.240.15 Load Average 0.08 0.24 0.16 Total Meniscus Length (cm) Pre-CycleResting 0.95 0.90 0.91 Pre-Cycle Varus 0.88 0.73 0.75 Load Post CycleResting 0.88 0.90 0.87 Post Cycle Varus 0.90 0.93 0.86 Load Average 0.900.87 0.85 Capsular Displacement from Tibial Edge (cm) Pre-Cycle Resting0.06 0.13 0.10 Pre-Cycle Varus 0.06 0.18 0.11 Load Post Cycle Resting0.06 0.23 0.17 Post Cycle Varus 0.07 0.17 0.16 Load Average 0.06 0.180.14

TABLE 4 Donor 4 Baseline Lesion Repair Meniscus Beyond Femoral-TibialBaseline (cm) Pre-Cycle Resting 0.13 0.39 0.17 Pre-Cycle Varus 0.13 0.380.16 Load Post Cycle Resting 0.13 0.40 0.22 Post Cycle Varus 0.14 0.470.20 Load Average 0.13 0.41 0.19 Total Meniscus Length (cm) Pre-CycleResting 0.55 0.88 0.68 Pre-Cycle Varus 0.57 0.88 0.71 Load Post CycleResting 0.55 0.89 0.78 Post Cycle Varus 0.60 0.87 0.69 Load Average 0.570.88 0.72 Capsular Displacement from Tibial Edge (cm) Pre-Cycle Resting0.14 0.27 0.12 Pre-Cycle Varus 0.13 0.30 0.11 Load Post Cycle Resting0.12 0.33 0.16 Post Cycle Varus 0.12 0.45 0.09 Load Average 0.13 0.340.12

TABLE 5 Donor 5 Baseline Lesion Repair Meniscus Beyond Femoral-TibialBaseline (cm) Pre-Cycle Resting 0.18 0.34 0.21 Pre-Cycle Varus 0.24 0.340.20 Load Post Cycle Resting 0.19 0.24 0.22 Post Cycle Varus 0.24 0.310.24 Load Average 0.21 0.31 0.22 Total Meniscus Length (cm) Pre-CycleResting 0.94 0.72 0.68 Pre-Cycle Varus 0.83 0.88 0.76 Load Post CycleResting 0.93 0.84 0.82 Post Cycle Varus 0.73 0.98 0.75 Load Average 0.860.86 0.75 Capsular Displacement from Tibial Edge (cm) Pre-Cycle Resting0.07 0.16 0.11 Pre-Cycle Varus 0.07 0.19 0.08 Load Post Cycle Resting0.07 0.15 0.11 Post Cycle Varus 0.05 0.17 0.07 Load Average 0.07 0.170.09

TABLE 6 Donor 6 Baseline Lesion Repair Meniscus Beyond Femoral-TibialBaseline (cm) Pre-Cycle Resting 0.06 0.22 0.20 Pre-Cycle Varus 0.13 0.290.20 Load Post Cycle Resting 0.10 0.41 0.16 Post Cycle Varus 0.11 0.360.21 Load Average 0.10 0.32 0.19 Total Meniscus Length (cm) Pre-CycleResting 0.70 0.72 0.72 Pre-Cycle Varus 0.68 0.75 0.61 Load Post CycleResting 0.68 0.73 0.68 Post Cycle Varus 0.62 0.68 0.65 Load Average 0.670.72 0.67 Capsular Displacement from Tibial Edge (cm) Pre-Cycle Resting0.07 0.18 0.08 Pre-Cycle Varus 0.07 0.22 0.11 Load Post Cycle Resting0.09 0.31 0.13 Post Cycle Varus 0.06 0.27 0.15 Load Average 0.07 0.250.12

Additionally, the following tables (i.e., Tables 7-12) show averages forthe baseline meniscal extrusion, the lesion meniscal extrusion, and therepair meniscal extrusion for each of the six samples. These tables alsoshow Percent Extrusion Increase from Baseline to Lesion (%), PercentExtrusion Decrease from Lesion to Repair (%), and Percent RepairDifference from Baseline Condition (%).

TABLE 7 Donor 1 Repair Meniscal Extrusion Extrusion Extrusion Difference(as a percentage of Increase Decrease From the total length from fromBaseline Base- Baseline to Lesion to Condition line Lesion Repair Lesion(%) Repair (%) (%) Aver- 27.1 34.8 26.8 7.7 8.1 −0.3 ages

TABLE 8 Donor 2 Repair Meniscal Extrusion Extrusion Extrusion Difference(as a percentage of Increase Decrease From the total length from fromBaseline Base- Baseline to Lesion to Condition line Lesion Repair Lesion(%) Repair (%) (%) Aver- 24.6 47.6 31.3 22.9 16.2 6.7 ages

TABLE 9 Donor 3 Repair Meniscal Extrusion Extrusion Extrusion Difference(as a percentage of Increase Decrease From the total length from fromBaseline Base- Baseline to Lesion to Condition line Lesion Repair Lesion(%) Repair (%) (%) Aver- 8.3 27.5 18.6 19.1 8.9 10.3 ages

TABLE 10 Donor 4 Repair Meniscal Extrusion Extrusion ExtrusionDifference (as a percentage of Increase Decrease From the total lengthfrom from Baseline Base- Baseline to Lesion to Condition line LesionRepair Lesion (%) Repair (%) (%) Aver- 23.3 46.6 26.2 23.2 20.4 2.9 ages

TABLE 11 Donor 5 Repair Meniscal Extrusion Extrusion ExtrusionDifference (as a percentage of Increase Decrease From the total lengthfrom from Baseline Base- Baseline to Lesion to Condition line LesionRepair Lesion (%) Repair (%) (%) Aver- 24.8 36.0 28.9 11.2 7.1 4.1 ages

TABLE 12 Donor 6 Repair Meniscal Extrusion Extrusion ExtrusionDifference (as a percentage of Increase Decrease From the total lengthfrom from Baseline Base- Baseline to Lesion to Condition line LesionRepair Lesion (%) Repair (%) (%) Aver- 14.9 44.4 28.9 29.5 15.5 14.0ages

These examples show that a lesion can be produced after physicallydisrupting an intact capsule and meniscotibial ligaments. The manuallyproduced lesions caused instability (i.e., extrusion of the meniscus).Repairing these injuries resulted in improvement in the stability of themeniscus, although not a complete restoration of stability (i.e., fullbaseline of an uninjured, intact capsule and meniscus, a time zerostate).

The description of the different advantageous arrangements has beenpresented for purposes of illustration and description, and is notintended to be exhaustive or limited to the embodiments in the formdisclosed. Many modifications and variations will be apparent to thoseof ordinary skill in the art. Furthermore, different advantageousembodiments may describe different advantages as compared to otheradvantageous embodiments. The embodiment or embodiments selected arechosen and described in order to explain the principles of theembodiments, the practical application, and to enable others of ordinaryskill in the art to understand the disclosure for various embodimentswith various modifications as are suited to the particular usecontemplated.

What is claimed is:
 1. A method of repairing a capsular disruption and a meniscal extrusion comprising: inserting one or more anchors through a knee joint capsule at the capsular disruption, wherein the capsular disruption comprises at least one of a tear of coronary fibers of a meniscotibial ligament or a tear of coronary fibers of a meniscofemoral ligament; and securing the knee joint capsule to a knee joint structure to decrease a length of the meniscal extrusion, wherein securing the knee joint capsule to the knee joint structure comprises inserting the one or more anchors into the knee joint structure, wherein the knee joint structure comprises at least one of a tibia, a femur, tibial periosteum, or femoral periosteum.
 2. The method of claim 1, wherein the one or more anchors comprises a suture anchor or a soft tissue anchor.
 3. The method of claim 1, wherein inserting one or more anchors through the knee joint capsule comprises inserting a first anchor and a second anchor.
 4. The method of claim 3, wherein the first anchor is inserted below a knee joint line and at an anterior distal portion of the knee joint capsule, and wherein the second anchor is inserted posterior to the first anchor.
 5. The method of claim 3, wherein the second anchor is inserted through the knee joint capsule within about 2 cm of the first anchor.
 6. The method of claim 5, wherein the second anchor is inserted through the knee joint capsule within about 1 cm to about 1.5 cm of the first anchor.
 7. The method of claim 3, wherein the method further comprises securing sutures from each of the first and second anchors to the opposite anchor.
 8. The method of claim 3, wherein the method further comprises securing the first anchor to the second anchor with a flexible strand.
 9. The method of claim 1, wherein inserting one or more anchors through the knee joint capsule comprises percutaneously inserting the one or more anchors.
 10. The method of claim 1, wherein the method further comprises drilling a hole in a bone for inserting the anchor.
 11. The method of claim 1, further comprising: visualizing a spinal needle with an arthroscope to identify a location for inserting one or more anchors through the knee joint capsule, wherein the spinal needle is inserted through the skin into the knee joint structure.
 12. The method of claim 1, further comprising: inserting a biological product into the knee to stimulate healing.
 13. The method of claim 12, wherein the biological product is selected from the group consisting of stem cells, bone marrow concentrate, platelet-rich plasma (PRP), a tissue graft, and combinations thereof.
 14. The method of claim 1, wherein the knee is a knee of a patient, a cadaveric knee, or a synthetic knee.
 15. The method of claim 1, wherein the capsular disruption comprises the tear of coronary fibers of the meniscotibial ligament, and wherein inserting the one or more anchors into the knee joint structure comprises inserting the one or more anchors into the tibia. 